Symbols

In the health care setting, uniform styles and colors help patients distinguish the various caregivers. Many patients, particularly older adults, were unhappy when nurses stopped wearing caps. The white uniform and cap were symbols that helped older adults distinguish nurses from other caregivers. For this reason, nurses in some nursing homes continue to wear white uniforms and caps. In other settings, nurses may not wear any distinguishing uniform, or they may wear scrub suits. Street clothes, such as a navy blue outfit with an identifying name tag, are preferred in some agencies, particularly in home care or public health. This can be confusing to older adults because such clothing is not distinctive enough to identify the individual as a nurse and because many older adults cannot read the small print on name tags. Older adults have been heard to say to caregivers, “Who are you? What are you going to do to me?” Although nurses may not place much importance on wearing a uniform, it does play a role in communication.

Tone of Voice

Think of the sound of a whisper, shout, or whine. Try saying, “I don’t want to do that,” first in a whisper, shout, and whine, and then in a normal speaking voice. Was your understanding of the message the same in each situation? Probably not. To survive we learn early in life to understand that tone of voice is a fairly reliable way of judging a person’s emotions. Because the nonverbal message is so strong, we typically respond to the emotion we perceive from the tone of voice and may not even hear the words. When a person shouts at us, we normally shout back. Shouting is often associated with anger or displeasure, yet many people shout in an attempt to communicate with someone who is hard of hearing. Shouting is not an appropriate way to deal with hearing problems because our tone of voice may lead the hearing-impaired person to think we are angry with him or her when this is not the case. Speaking in a low tone of voice close to the person’s good ear is much more effective. Use of other nonverbal methods of communication, such as communication boards or gestures, can also help.

Body Language

You walk past a room and observe a nurse standing in the doorway, with his or her head sticking into the room and body still in the hallway. The nurse’s mouth is saying, “Can I help you?” but the body is saying, “I’m in a hurry. You really don’t want anything, do you?” We communicate many things by how we move, stand, sit, and position our bodies. In dealing with all patients, but particularly older adults, it is important that we be aware of what we are communicating through our body language.

In situations in which the words and body language are conveying two different messages, most people respond to the body language. Standing at the door, hurrying down the hallway, sitting behind the nurses’ station, and working in the medication or treatment room all communicate that the nurse is busy and does not want to be interrupted. Many older adults and their families are intimidated by this body language and may hesitate to interrupt, even to report serious concerns. Nurses must be careful not to create barriers between themselves and their patients. Going into the rooms to talk with patients, sitting down at eye level with residents, and spending time in the lounge with visitors are all ways of nonverbally communicating that you are truly interested and concerned.

Another part of nonverbal communication involves watching for the messages that patients are communicating to us through their body language. For example, patients who slump down or slouch in their chairs may be communicating fatigue or physical weakness, or they may be communicating a lack of interest, sadness, defiance, or a number of other things. Turning away from the nurse could indicate anger, fear, or lack of interest. When body language says something different from the words, believe the body language. Explore the situation using techniques such as reflective or open-ended statements. (These techniques are clarified later in the chapter.)

Space, Distance, and Position

Physical space, distance, and position are other ways we communicate. The study of the use of personal space in communication is referred to as proxemics. Personal space refers to how close we allow someone to get to us before we feel uncomfortable. The amount of space that separates two individuals when they communicate is significant. In the traditional American culture, most people are comfortable when strangers are 12 feet or more away. This is considered public space; at this distance, there is no real positive or negative connection with the other person. Between 4 and 12 feet is considered social space. This is a comfortable distance for a casual relationship, in which communication is at an impersonal level. If a nurse stays this far away from his or her patients, the message being communicated is indifference. A distance of 18 inches to 4 feet is considered personal space. This is the optimal distance for close interpersonal communication with another person. A nurse who communicates from within this space is usually viewed as concerned and interested. The space within 18 inches of the body is considered intimate space. Most people allow only trusted individuals to get this close. Entering the intimate space without permission is usually perceived as a threat.

A nurse or other caregiver may approach an older adult to provide care or treatment and, without thinking, enter this intimate space too quickly. (Because of the nature of their work, nurses and other caregivers are used to entering a person’s intimate space, and they take this for granted.) An older adult who has poor vision or hearing, who has been sleeping, or who is not totally alert may be startled by the nurse’s approach. He or she may not be able to recognize the nurse as a trusted person at first and may strike out verbally or physically. This response results from fear of physical attack. It is essential that nurses recognize the importance of personal space and attempt to get the older adult’s attention and (if possible) permission before attempting to perform any physical care.

Gestures

Gestures are a specific type of nonverbal communication intended to convey ideas. Gestures are highly cultural and generational; those that are acceptable in one culture may be considered offensive in another. Some gestures that are accepted today as commonplace were once considered crude or insulting. Gestures that have a certain meaning in one culture may have a different meaning in another. For example, nodding the head up and down means yes in most cultures, but to some Eskimo tribes it means no. Before using gestures, it is wise to determine that both parties have the same understanding of just what a particular gesture means.

Gestures are helpful for people who cannot use words. After a stroke, many individuals suffer from a condition called aphasia. Because of brain damage, these individuals may not be able to recognize words or to “find” the words they want to use. This inability to communicate wants, needs, and feelings is often frustrating to the affected person, and the use of gestures and other nonverbal forms of communication can be effective.

Facial Expressions

Facial expressions are yet another form of communication. The human face is most expressive, and facial expressions have been shown to communicate across cultural and age barriers. Smiles, frowns, and grimaces appear to have the same meaning whether you are in the outback of Australia or in a boardroom on Wall Street. Humans respond to facial expressions from the time they are born. We tend to mirror the expressions of the person with whom we are communicating: Smiles tend to elicit smiles, and frowns elicit frowns. Fear, anger, joy, and a variety of other emotions can be conveyed by a simple change in facial expression. Nurses need to be aware of this fact and ensure that their expressions communicate what is intended. Too often, nurses are preoccupied while interacting with an older adult. A frown may lead the individual to think that he or she has done something wrong. A wrinkled nose, particularly when cleaning up an episode of incontinence, could be viewed as a lack of acceptance. A smile when listening to serious concerns may make the person wonder whether the nurse really cares about what is being said.

Eye Contact

“Look me in the eye” is a phrase many white Americans have heard. Looking someone in the eye is perceived in our culture and other cultures as a measure of honesty. Yet in some cultures (e.g., African Americans and some groups from Southeast Asia), averting the eyes communicates respect. When dealing with older adults, it is important to be sensitive to the meaning of eye contact for them. Face-to-face, eye-to-eye contact can be helpful when communicating with older adults, providing this does not frighten or intimidate them. Eye contact is often interpreted to be a sign of attentiveness and acceptance. Face-to-face contact also maximizes the chance that an older adult with hearing problems can read lips if necessary. Sitting at the bedside may facilitate eye contact.

Pace or Speed of Communication

Nurses tend to be substantially younger than the aging people they serve. The resulting difference in rate of speech and movement can be overwhelming and frustrating to older adults. Many choose not to respond or interact with younger nurses because they feel they are being hurried. Do not become impatient or uneasy with silence; give the older person enough time to think and organize a response. Provide encouragement and reassurance that they will have all of the time they need. Nurses have too often been observed completing sentences for older adults when they should have the patience to wait for the individuals to organize their thoughts and speak. Many times, nurses complete the communication according to their own way of thinking rather than waiting to hear what the older adult wants to say. This is disrespectful and demoralizing. Patience and active listening are greatly needed skills when working with older adults. “Slower is better” should be the motto impressed in the mind of anyone who chooses to work with older adults.

Time and Timing

Timing is related to the pace of communication, but it has other distinct implications as well. The amount of time a person must wait after seeking attention is important. Delays in response to a call light or direct request from a person may be interpreted as a lack of concern, even if this is not intended. The response to this perception may manifest in anger, displeasure, anxiety, fear, and many other feelings. Studies have shown that nurses take longer to respond to terminally ill patients. Nurses also tend to give delayed responses to demanding individuals. This can set up a vicious cycle, because the longer a person waits for a response, the greater his or her anger, fear, and anxiety becomes. This only increases the demanding behaviors, which often occur in an attempt to reduce fear. If the older adult’s needs are dealt with promptly, the number of demands tends to decrease not increase. Making older adults wait unnecessarily constitutes a subtle form of abuse.

Many older individuals have an altered sense of time. A message that is communicated too early may lead to either forgetfulness or to repeated questions of “Is it time yet?” A message that is communicated too late may lead to distress and frustration. Older adults often need more preparation time than younger individuals need to get ready for an activity such as going to the bathroom or getting necessary items together. Communicating an exciting message late in the evening (whether it is good or bad news) may disturb older adults to the point that they are unable to sleep. Nurses need to be aware of these issues so that they can choose the proper time to communicate.

Touch

Touch is a form of communication. No words are required, and there is no need for high-level sensory or cognitive functioning. When all else fails, touch is left. Caring touch is a basic need of all humans, and many older adults suffer from touch deprivation. Many older people, particularly those who have lost their spouses and have little contact with children or other family, have no one to meet this need. Research shows that psychotic patients and older adults are touched the least by caregivers. Those who most need physical contact and the comfort provided by touch receive the least.